CPRS Sample Templates Based on PCMHI Co-Located Collaborative Care ...

[Pages:33]CPRS Sample Templates Based on PCMHI Co-Located Collaborative Care Training Tools

Note: The templates provided here are intended to display local CPRS templates implemented in the field. These are not nationally mandated templates, but rather demonstrations of local

practices which can be adapted for local site utilization. Adaptation may be needed for local coding requirements for various disciplines.

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Table of Contents

CCC Initial Appointment: Functional Assessment......................................................................... 3 Example from Dr. Joe Barron, Bay Pines ................................................................................... 3 Example from Dr. Kristen Perry, Seattle .................................................................................... 6 Example from Dr. Beret Skroch, Minneapolis............................................................................ 8 Example from Dr. Joel Baskin, North Texas (Non-Prescribing Provider) ............................... 10 Example from Dr. Joel Baskin, North Texas (for Psychiatrists/APRNs/PAs/Clinical PharmDs) ................................................................... 13 Example from Dr. Rachel Colbert, Martinsburg....................................................................... 17

CCC Follow-Up Appointment CPRS Template ........................................................................... 21 Example from Dr. Joe Barron, Bay Pines ................................................................................. 21 Example from Dr. Kristen Perry, Seattle .................................................................................. 23 Example from Dr. Peggy Arnott, Orlando ................................................................................ 24 Example from Dr. Rachel Colbert, Martinsburg....................................................................... 28 Example from Dr. Joel Baskin, North Texas (Medication Review Visit for Psychiatrists/APRNs/PAs/Clinical PharmDs) .......................................................................... 31

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CCC Initial Appointment: Functional Assessment

Example from Dr. Joe Barron, Bay Pines

PRIMARY CARE-MENTAL HEALTH INTEGRATION (PC-MHI) FUNCTIONAL ASSESSMENT

DEMOGRAPHICS: Name: |PATIENT NAME| Age: |PATIENT AGE| Sex: |PATIENT SEX|

|SC DISABILITIES + RATED|

Primary Care Provider: |PRIMARY CARE PRACTITIONER|, |PRIMARY CARE TEAM|

Length of Visit: {FLD:TEXT 10} minutes

{FLD:BUTTON []}Warm Hand-Off {FLD:BUTTON []}Scheduled Visit {FLD:BUTTON []}Walk-in

The veteran was appropriately identified and informed about the nature of PC-MHI services and this screening visit as well as limits of confidentiality.

Clinical Reminders are Due: {FLD:00 YES/NO}

Urgency of need for care: {FLD:BUTTON []} Routine {FLD:BUTTON []} Stat Appropriate setting for care: {FLD:BUTTON []} Outpatient {FLD:BUTTON []} ER _____________________________________________________

MAIN CONCERN: Veteran was referred by physician/medical team due to {FLD:TEXTBOX}

Problem History (Duration/Frequency/Intensity): {FLD:TEXTBOX}

Treatment History for Problem: {FLD:TEXTBOX}

Factors that Improve/Exacerbate Problem, if applicable: {FLD:TEXTBOX}

Any Other Concerns of Veteran or Relevant Mental Health History: {FLD:TEXTBOX}

How Presenting Problem Impacts the Following: -Sleep: {FLD:TEXTBOX}{FLD:BUTTON []}No changes -Work/School: {FLD:TEXTBOX}{FLD:BUTTON []}No changes -Relationships/Interpersonal: {FLD:TEXTBOX}{FLD:BUTTON []}No changes

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-Leisure/Recreation: {FLD:TEXTBOX}{FLD:BUTTON []}No changes -Physical/Medical/Pain:{FLD:TEXTBOX}{FLD:BUTTON []}No changes -ETOH/Illicit Substance Use/Tobacco/Caffeine: {FLD:TEXTBOX}

Symptom Measurements: PHQ9 (Depression): (RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-19 Moderately severe; 20-27 Severe)

GAD7 (Anxiety): (RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-21 Severe)

PCL-5 (Trauma-Related Symptoms): (RANGES: 0-10: Minimal; 11-20: Mild; 21-40: Moderate; 41-60: Severe; 61-80: Very Severe symptoms)

AUDIT (Alcohol Use): (RANGES: A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.

WENDER UTAH RATING SCALE (Self-Report Measure of Childhood ADHD symptoms): (RANGES: Data suggest a cutoff score of 46 or higher correctly identified 86% of the patients with attention deficit hyperactivity disorder and 99% of the normal subjects.)

MONTREAL COGNITIVE ASSESSMENT (MoCA): (RANGES: 0-30; Score of 25 or less is indicative of possible cognitive dysfunction.)

BOMC (Orientation/Cognition): (RANGES: This screener has a range of 0 to 28. A score greater than 10 is consistent with the presence of a possible cognitive disorder. Values less than 7 are considered normal for the elderly.) _____________________________________________________

LETHALITY ASSESSMENT -Are you having thoughts of harming yourself or others? {FLD:00 YES/NO} {FLD:TEXTBOX} -Any history of suicide attempts: {FLD:00 YES/NO} {FLD:TEXTBOX} -Any history of violence: {FLD:00 YES/NO} {FLD:TEXTBOX} -Risk level: {FLD:BUTTON []}LOW {FLD:BUTTON []}MODERATE {FLD:BUTTON []}HIGH

{FLD:TEXTBOX} _____________________________________________________

MENTAL STATUS: {FLD:BUTTON []} Within normal limits {FLD:BUTTON []} Other: {FLD:TEXTBOX} _____________________________________________________

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_____________________________________________________

DIAGNOSTIC IMPRESSIONS: {FLD:TEXTBOX} _____________________________________________________

ASSIST PHASE:

Veteran was provided with tools for self-management including: {FLD:BUTTON []} Handouts on:{FLD:TEXTBOX} {FLD:BUTTON []} Online resources for: {FLD:TEXTBOX} {FLD:BUTTON []} Skills training in: {FLD:TEXTBOX} {FLD:BUTTON []} Education regarding: {FLD:TEXTBOX}

ACTION PLANNING: {FLD:TEXTBOX} _____________________________________________________

FOLLOW-UP PLAN:

{FLD:BUTTON []} Continue Care within PC-MHI. {FLD:TEXTBOX}. RTC in {FLD:TEXT 10} weeks {FLD:BUTTON []} Referral to General/Specialty Mental Health

{FLD:TEXTBOX}

Outcome and recommendations will be discussed with the referring provider and other relevant PACT team members as needed. _____________________________________________________

EDUCATION: Veteran was provided with opportunity to address any questions or concerns. The veteran was provided with written contact information. The veteran is aware of the Suicide Prevention Hotline number (1-800-273-8255) in case of crisis. If experiencing a mental health emergency, the veteran should present to nearest emergency room or call 911 immediately. _____________________________________________________

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Example from Dr. Kristen Perry, Seattle Primary Care Mental Health Integration Functional Assessment ---------------------------------------------------------------------Age: |PATIENT AGE| GENDER: |SEX| RACE: |RACE| |PRIMARY CARE TEAM| Current |PRIMARY CARE PROVIDER| Date: {FLD:DATE (TODAY)} Visit Duration: 20 min therapy (25 min face-to-face)

Brief evaluation with Veteran completed during which Veteran's questions and concerns were addressed and engagement in care was facilitated. Discussed nature/purpose of psychological treatment, the undersigned's role on treatment team, the use of information (including notations of care in CPRS), limits of confidentiality, and the voluntary nature of treatment. Veteran orally expressed informed consent to engage in this evaluation.

REFERRAL PROBLEM: {FLD:W-P2LINES}

HISTORY OF PROBLEM: Problem History (Duration/Frequency/Intensity): {FLD:W-P2LINES}

Treatment History: {FLD:W-P2LINES}

Exacerbating/Alleviating Factors: {FLD:W-P2LINES}

Other Problems of Concern to Veteran: {FLD:W-P2LINES}

FUNCTIONAL ASSESSMENT: Sleep: {FLD:YES/NO/UNKNOWN} Work: {FLD:YES/NO/UNKNOWN} Relationships: {FLD:YES/NO/UNKNOWN} Recreation: {FLD:YES/NO/UNKNOWN} Physical Activity: {FLD:YES/NO/UNKNOWN} ETOH: {FLD:YES/NO/UNKNOWN} Tobacco: {FLD:YES/NO/UNKNOWN} Drugs: {FLD:YES/NO/UNKNOWN} Caffeine: {FLD:YES/NO/UNKNOWN}

SAFETY/RISK ASSESSMENT: Are you feeling hopeless about the present or future? {FLD:YES NO} Have you had thoughts about taking your life? {FLD:YES NO} Have you ever had a suicide attempt? {FLD:YES NO} Danger to others: {FLD:YES NO}

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MEASUREMENT BASED CARE: PHQ-9 = PHQ-9 Q10 = GAD-7 =

MENTAL STATUS: Orientation and Consciousness: {FLD:MSE ORIENT} Appearance and Behavior: {FLD:MSE APPEAR} Mood and Affect: {FLD:MSE MOOD} Speech: {FLD:MSE SPEECH} Perceptual Disturbance: {FLD:MSE HALLUCINATE}{FLD:MSE PERCEPTUAL} Thought Process: {FLD:MSE THOUGHT PRO} Insight: {FLD:MSE INSIGHT TEXT}{FLD:MSE INSIGHT} Judgment: {FLD:MSE JUDGE TEXT}{FLD:MSE INSIGHT}

DIAGNOSIS: {FLD:W-P2LINES}

TREATMENT PLAN: Immediate Mental Health care needed. Crisis response initiated. Mental Health (non-urgent, within 14 days) needed. Next appointment: [INCLUDE CLINIC, DATE/TIME] Veteran declines Mental Health care. Addressed any concerns, and provided emergency contact numbers to Veteran: VA contact during working hours: ENTER PROVIDER NAME AND PHONE LINE 24 hour VA Veteran's Crisis Line: 1-800-273-8255, option 1 911

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Example from Dr. Beret Skroch, Minneapolis PRIMARY CARE/MENTAL HEALTH INTEGRATION EVALUATION AND TREATMENT PLAN PROCEDURES: 30?minute behavioral health provider evaluation and treatment for XX VETERAN SELF-REPORT/REASON FOR REFERRAL: TREATMENT PLAN:

Treatment goals negotiated with patient include: 1. 2.

INTEGRATED SUMMARY: DIAGNOSTIC IMPRESSIONS: Presenting Problem History (Duration/Frequency/Intensity): Treatment History of Presenting Problem: What Makes the Presenting Problem Better/Worse: Other Problems of Concern to Veteran:

IMPACT OF PRESENTING PROBLEM ON FUNCTIONING/DAILY LIFE Sleep: Physical/Nutrition/Exercise: Work: Relationships/Social Functioning: Recreation: Alcohol: Tobacco: Drugs: Caffeine:

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